complaint·April 22, 2025

Continued from LIC 9099 Throughout the course of the investigation, LPA reviewed all documents obtained and conducted telephonic interviews with additional credible witnesses and other relevant parties. The following was then determined: Regarding allegation “Due to insufficient staffing, residents are not given medication as prescribed”. It was alleged that staff are either administering medication late or missing dosages entirely as a result of ongoing staffing shortage. During interviews, the ED acknowledged that the facility has experienced staffing challenges; however, the ED emphasized that the facility maintains adequate staffing levels to compensate for employees who resign or call out due to illness. Furthermore, the ED stated that medication administration remains a top priority for the facility, and staff are committed to ensuring medications are distributed on time. The ED also reported that no complaints have been received from residents regarding delayed or missed medication doses. Med-Techs interviewed stated that the staffing shortages have been an ongoing issue for the past few months. However, they affirmed that all medications has been administered at the prescribed times and no dosages have been missed. Interviews with residents revealed that staffing deficits have directly impacted the quality of care provided to them. Specifically, concerns have been raised regarding delays in medication management, including missed or late medication administration, as well as extended wait times for resident assistance. To further investigate these concerns, LPA conducted a comparison of staff schedules, timecards, and personnel reports (LIC 500). The review confirmed that facility has occasionally employees calling out of their schedule. Also, multiple employees are no longer working at the facility, resulting in other staff members being required to work double shifts. In certain instances, employees were asked to report to work on their scheduled days off to ensure adequate coverage. Additionally, the LPA observed staffing gaps during shifts, with only one (1) caregiver and one (1) Med-Tech on duty to provide care for all residents in the assisted living unit. Furthermore, m edication audits were conducted on 12/31/2024, 03/20/2025 and 04/10/2025. During these audits, pill counts, Medication Administration Record (MAR) and Centrally Stored Medication and Destruction Record (CSMDR) were reviewed for ten (10) randomly selected residents. Continued on LIC 9099-C Continued from LIC 9099-C The LPA found discrepancies in eight (8) out of ten (10) resident’s medication, where the pill counts within bubble packs did not match the records documented on the CSMDR. Morning Med-Techs on duty were unaware if these discrepancies, while evening med techs reported uncertainty about how these errors occurred, stating that often there is a br eakdown in communication, documentation and medication administration between shifts. Based on information gathered during the course of the investigation, there is sufficient evidence to determine that shortage of staff is causing medication issues. Therefore, the above allegation “insufficient staffing” is deemed SUBSTANTIATED at this time. Medication’s concern will be addressed under a separate complaint, referenced by complaint #29-AS-20250318091807. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 9099-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.